CPT 76811Radiology

Ob us detailed sngl fetus

CPT 76811 is a detailed ultrasound examination of a single fetus performed during pregnancy to assess fetal anatomy, growth, and development. This comprehensive imaging study evaluates the baby's organs, limbs, and overall health in greater detail than a standard prenatal ultrasound.

Showing rates for

National Average

Base Medicare rate

$172.08

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.9

PE RVU (NF)

3.35

MP RVU

0.07

Total RVU

5.32

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Ensure comprehensive documentation of all required anatomic structures including intracranial anatomy, four-chamber heart view, spine, stomach, kidneys, bladder, and extremities with measurements
Impact: Missing even one required element can result in downcoding to 76805 ($89.16) representing a $82.92 loss per claim
Bill 76811 only once per pregnancy unless repeat examination is medically necessary with clear documentation of changed clinical circumstances or new findings
Impact: Routine repeat 76811 without documented medical necessity results in denial; appeals success rate under 20% without strong justification
Use 76811 for high-risk or targeted examinations; use 76805 for routine anatomic surveys to avoid automatic audits and downcoding
Impact: Inappropriate use of 76811 for standard screenings triggers payer edits and increases audit risk by 300-400%
Document time spent and complexity when performing 76811 after abnormal findings on 76805 performed elsewhere, including comparison with prior images
Impact: Clear documentation of medical necessity for detailed re-evaluation supports payment and reduces denial rate from 35% to under 10%
Verify payer-specific policies regarding 76811 versus 76805; some commercial payers require pre-authorization for 76811
Impact: Lack of pre-authorization results in immediate denial of $172.08; retroactive authorization success rate is only 40-50%
When billing globally, ensure both the technical and professional components are performed at your facility; split billing with modifier 26 or TC when components are separate

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Frequently asked questions

What is the difference between CPT 76811 and 76805?

CPT 76811 is a detailed fetal anatomic examination typically performed for high-risk pregnancies or suspected anomalies, requiring comprehensive evaluation and documentation of multiple anatomic structures. CPT 76805 is a standard anatomic survey for routine screening. The 76811 examination is more time-intensive, requires more detailed documentation, and reimburses at $172.08 compared to 76805's lower rate, but requires clear medical necessity beyond routine screening.

How many times can you bill CPT 76811 during a pregnancy?

CPT 76811 is typically billable once per pregnancy, usually performed between 18-22 weeks gestation. Additional 76811 examinations require clear documentation of changed clinical circumstances, progression of identified anomalies, or new maternal/fetal conditions warranting repeat detailed evaluation. Repeat examinations without documented medical necessity will be denied by most payers.

Does Medicare cover CPT 76811?

Yes, Medicare covers CPT 76811 when medically necessary for evaluation of high-risk pregnancies or suspected fetal anomalies, with 2025 reimbursement of $172.08. However, Medicare coverage of obstetric services is limited as most pregnant patients are under age 65. When applicable (such as disabled beneficiaries), standard medical necessity requirements apply.

What diagnosis codes support medical necessity for CPT 76811?

Diagnosis codes supporting 76811 include O35.xx series (maternal care for suspected fetal abnormality), O36.xx series (maternal care for other fetal problems), Z36.xx (encounter for antenatal screening), advanced maternal age (Z35.5), maternal diabetes (O24.xx), and history of fetal anomaly (O35.1xx). The diagnosis must justify the need for detailed examination beyond routine screening.

Can you bill CPT 76811 and 76816 together?

Yes, CPT 76811 (detailed single fetus) and 76816 (re-evaluation) can be billed together when performed on different dates or when 76816 represents follow-up of a specific finding from the initial detailed examination. When performed on the same date, modifier 59 may be required with clear documentation of distinct clinical purposes. The re-evaluation must be separately identifiable and medically necessary.

What modifiers are most commonly used with CPT 76811?

The most common modifiers for CPT 76811 are modifier 26 (professional component only when interpretation is separate from technical component), modifier TC (technical component only), and modifier 59 (distinct procedural service when billing with other ultrasounds same day). Modifier 76 or 77 may be used for repeat examinations but require strong documentation of medical necessity.

What are the RVU values for CPT 76811 in 2025?

For 2025, CPT 76811 has a work RVU of 1.9, practice expense RVU of 3.35 (both facility and non-facility), and malpractice RVU of 0.07, totaling 5.32 RVUs. With the 2025 conversion factor of 32.3465, this results in a Medicare payment rate of $172.08 for both facility and non-facility settings.